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I , <br /> APPLICATION FOR WELLIPUMP PERMIT ! <br /> � 1 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 I <br /> y <br /> NOR-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpOlmtel <br /> AFMICAMN 1914ERE BY MADE TO THE SAN JOAQUN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORN DEWSRED.TRUE APPLICATION IS MADE M COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPOM'E]NT TITLE,/CHA.P`TE11 B-11`16.]AND TH`E STANDARDS OF SAN MAOUNI COUNTYLFFUEEFC HEALTH SERVIOEB,ENVIRONMENTAL HEALTH OMM.. <br /> J08 AOORESMR AP((NF-\ f (V -�z N(,1`JR"YLD �1• P�ACL\ ,�RA7 r o JALL. CRY S (�L��n1 ' " PARCEL SOEIARU <br /> OWRER'8NAME SLy�.KIV�1 V1A.f.`1-D�A SCU0101 &SU G1J-AOOM.. 1932 kL tE P.`Ask Or\v+. RHONE, �p <br /> CONTRACTOR PAIL xlsai�O� Ivu. ADORES. I'll�l^�e LCI^L �p\W1 X13 Me - FMHE. 511- Tutt I{!II <br /> BUB CONTRACTOR W I oI k AOORE88 Y�V[7�X Sl . IrtVa VlS74 UCe 9c�i RIONE) ; _ <br /> TYPE OF WELL/PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITONINo WELLN IEf ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROBS{ONNECT REPAm II ❑ VAPOR E RAICN WELL I J <br /> ❑N.Y❑RMHHI N.P. - DEPTH FUMF SET_R. '� FIVET WATER LEVEL 0 <br /> (TYPE OF MMPI <br /> ❑ OIR-0FBERVICE WELL ❑ MOPIwMAL WELL e f SDE BONING 1 B <br /> I <br /> ❑DEBTm1CTMW. 'I <br /> IV <br /> INTENDED USE TYPE OF WELL CONSTRUCTION EFECWCAIWNS I A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OFWELLEXCAVATION 1,5 o4 U I VIA.OF CONDUCTOR CASMO INA O <br /> ❑ DOMESTM"VATE ❑GRAVEL PAMmIyE TYPE OFCABmORREFLNVC -1 RVA INA.OF WELL CASINO AJA O <br /> ❑ PUBLICAl1UMKSM 0VR1rEN DEPTHOFOIIOUTSEAL JLT�� 'I SPECIHCATR)N NCI' R <br /> ❑ mRIGAT10NIAG ❑OTHER GROUT SEAL METALLED�BV Tvw^�ti 17. SMUT BMNO NAME WAOAiI WEY� E 1 <br /> ❑ wwomNO GROUT SEAL PUMPED: BEEVr ❑Ne F' '1 CONCI@fE PEDESTAL BY ONLLEIk❑Yr *A. S <br /> APPROX.DEPTH ' LOCKING CHESTER BOI(RHOVE PPE I. s <br /> PIIOPOi®CONtTRVCTONID19tLING NN MOS: MIID ROTARY Am RDTARY AUGER_ CABLE OT.,__ '1 <br /> I NERBY CERTIFY THAT I HAVE PIEPAMO THIS APPICATR)N AND THAT THE WMe(WILL BE DONE N ACCOADANCE WITH BAN JDAOUN COUNTY OIONANCES.STATE LAWS.AND RULES!ANO <br /> MOU ATIONS OF THE BAN JOAQUN COIIIRY. NOW OWNER OR LICENSED AGENT'S=NATURE"PRIVIES THE MULOWIM:'t CERTIFY THAT M TIRE PERFORAANCE OF THE WORN FOR WHICH I <br /> Me PERMIT 18ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOMXMM'S COM AMM LAWS OF CALMANU.' CONTFL&IZMII'8 IIR91O OR S ONlAACTRO SKMATUM CEMVES <br /> THE FOLLOWING: -1 CERTIFY THAT NTNE PEIEORMAME Of THE WORK FOR WHICH TME PERMIT 19 ISSUED.1 SHALL INIPby PI RKINS SUIUMCT TO WNUX WO CONVERSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST GALL N HOURS N ADRIAN"Mat ALL REQIMED MSPECTMNS AT I] eami ". COMPLETE pUW M AT LOWER AREA"'OV""' I <br /> e1..e z i •ti PTI. 1 <br /> ' ROT RAM Ipew le 88.1.1 BSM. -is <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOU NEDI G THE PROPERTY- A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> E. OUTLINE OF TRE PROPERTY.O1 VIMMMNB AND NORTH OVECT ON. EXPANSION Of SEWAGE MSPOSAL SVSTE149. <br /> O. pM1EMSMNED OUTLINES AND LOCATION OF ALL EXm AND PROPOSED 9. LO CATMNOFWELL9WR)1M MONS Op ONE HUMORED FU R. <br /> BTRVCTKRE9.VA:LUIRM COVERED AREAS SUCH AS PATIOS.DI9VEWAYB,AND WALKS. ON THE RIOPERTY OR ADJURNNG PROIFIITY. <br /> r <br /> t <br /> '— — OEIMTMFNT <br /> ME any I. --_— <br /> g_ <br /> Ora.L.IIrGM BT Pu.y Irlleeetlm SY � D.I.—=V <br /> Orinstlen irPrHIB..8Y �� DHS <br /> C. . <br /> �i <br /> ACCOUNTING ONLY: AIDE FACT IV <br /> Pa Cab" FEEINFO AMOUNTR TTM CMICIKIMASH 9Y DATE <br /> ` PEIMITISFAVICE REQUEST MUNIM, INVpICE <br /> i <br /> Pub 4e9ltb Se".-EnvirO.173(1197) <br />